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Overview of Cultural Safety in Nursing and Healthcare


Discuss about the Cultural Safety In Nursing And Healthcare.

In this chapter of the report, scholarly articles of various authors are reviewed in order to get the idea of cultural safety in nursing and healthcare. In literature review section, current knowledge of cultural safety in healthcare including substantive findings is delineated. Saudi Arabia has been becoming ethnically diverse and the people are witnessing cultural blending in Saudi Arabia as employees come from various backgrounds and countries in Saudi Arabia. In this chapter of the study, concepts of cultural safety in nursing and principles of nursing practices are discussed from theoretical perspective. Theories related to the cultural safety in nursing and healthcare are explained. At the end of the argumentative discussion, gap in literature is given identifying literature gap in the study. Discussion in this section is given from secondary sources from various original and new experimental works.    

In this literature review section, secondary data have been used in order to present the theoretical understanding of the concept. The researcher has searched over internet and university library in order to get the related journals, articles and books of the topic. The search terms of this research topic those the researcher used were ‘cultural safety’, ‘service quality’, ‘patient safety’ and ‘nursing principles’. The researcher mainly used the database like Google Scholar in order to search the articles and journals to get the idea. In addition, the researcher also used the databases like CINAHL Plus, ERIC, MEDLINE and Nursing References Centre in order to access the premium online journals. The parameters mainly used in searching the data were credible sources and most of the journals were taken from reputed publishing houses. Data have been collected from books, journals, websites, online articles and knowledge forum of Nursing. Specific Arab based data have not been collected due to inadequate data on nursing. The researcher has used 6 books and 24 journal articles in order to access them. The exclusion criterion of the data search was that the researcher used the journals and books which have been published only after 2013. Therefore, the sources that have been used in this study are not older than 5 years. Therefore, the researcher has used credible and recent sources of information. 

As opined by Wepa (2015), cultural safety is effective nursing practice of an individual or family from another culture which is determined by that individual or family. The concept of cultural safety has come from nursing education and nursing culture ranges from age or generation to sexual orientation and gender. The concept of nursing education and principles are associated with religious beliefs, occupation and disabilities. As argued by McCall and Lauridsen (2014), unsafe cultural practice can be defined through the actions that demean identification of the culture. In this relation, cultural principles are related to aim to develop the status, improve the service of health, differences among various people and understand the unique power of nursing and health services. Cultural safety concept devised from the leadership of nursing in the year 1989 and this concept first came in New Zealand by Maori nursing students. In the previous time, nursing schools were mono-cultural in New Zealand and Australia. Furthermore, in Australia, cultural safety concept in nursing was developed in social work and in education. In workplace, cultural safety is met when nurses do the actions related to respect, recognise, nurture and cultural identification of various people. Safety of the people has to meet with the needs, rights and expectations of the service users in healthcare. As further added by Richardson et al. (2017), cultures in health are included spiritual beliefs, ethnic group, migrant experiences and socio-economic condition of the people. The nurses and midwife deliver the health services and these services can reflect upon their cultural identity, it can recognise the impact of personal culture on professional service and practices. Unsafe cultural practice in healthcare is related to actions of disempowering and diminishing the cultural identity and safety of the individuals.

Theoretical Perspectives and Principles of Cultural Safety in Nursing Practices

The following themes emerged as a result of in-depth study on the subject matter and analysis of various authentic and scholarly resources like peer reviewed research papers, journals, articles and scientific studies. Important aspects of the subject have been recognised in the above method and distinctive themes emerged in the process. Some themes have sections and sub sections which have been clarified lucidly in the following paragraphs. 

Principle one: to improve well-being and health status of the individuals

Cultural safety in nursing applies in making the relationship through focusing on health of the individuals to gain positive outcome and well-being. Nurses need to acknowledge the practices and beliefs that differ from them. The beliefs of the service users may differ in terms of generation, occupation and ethnic origin, however; healthcare professionals need to serve them to improve health status of the individuals (Wepa 2015). In case of Saudi Arabia, culture is conservative and deeply religious and the nurses behave maintaining the prohibition in the society (Muller et al. 2015).

Principle two: to develop the delivery of nursing and health services

The delivery of health services can be made culturally safe when nurses can make a healthy relationship with service users. The nurses accept the personal analysis of power relations and they try to empower the service users. Nurses feel free to express their measurement of risks of service users and focus on serious and intrusive intervention. Healthcare providers need to understand the own cultural identity and reality. Nurses apply the concept of social science to underpin health services (Hall et al. 2014). Nurses provide service with diverse needs and the services must be safe.

Principle three: make differences among the individuals who are getting treatment and accept the differences

Culturally safe in healthcare is a broad concept to recognise the dissimilarities within healthcare centres, employment, education and social interactions that can solidify the microcosm of differences. The nurses need to understand cause and effect relationship with the service users and their views on politics, social, housing, employment status, psychological conditions and personal experiences (McCall and Lauridsen 2014). Nurses’ principle supports the idea of accepting the legitimacy of diversity and differences in social structure. Healthcare professionals need to concern in improving the quality of service to service providers.

Principle four: to understand the power of healthcare on persons’ and their families

Cultural safety has its focus on health care providers’ own culture, attitude and life experiences. Healthcare providers need to focus on their own practices to make a balance of power relationship so that each of the service users may receive effective service (Alonso et al. 2015). Nurses need to prepare themselves in order to resolve the tension between health care centres and culture of the nurses.

Current Knowledge and Findings of Cultural Safety in Healthcare

This is a conceptual model to provide a framework to investigate about health services and examine the quality of healthcare services. This concept of nursing and healthcare was established by Avedis Donabedian and he developed this model in the year 1966. According to Qu et al. (2014), Donabedian model speaks about the quality of care and it can be categorised into three categories, process, structure and outcomes.

The structure explains about the context through which care is delivered and it is related to the staff, hospital building, equipment and finance. These factors in healthcare control of patients, providers in the healthcare system. These factors also measure the quality of healthcare.

Process refers to the transaction between providers and transaction throughout the delivery of healthcare process. The process can be meant the sum of each action in health care and these factors are related to the preventive care, patient education, diagnoses and treatment facility. Process in healthcare can be further differentiated to deliver the better care to the service users in order to increase interpersonal bonding (Qu et al. 2014).

Lastly, outcomes in this model describe about the impact of healthcare in the health status of the individuals. Outcomes generally are the effects of healthcare on changes of a health condition, population and behaviour of the staffs. Outcomes indicate the improving condition of the health status of the service providers. 

Nursing care concept needs to be carried through a variety of organisational method.

Team nursing concept was originated in the between the 1950s and 1960s. Team nursing concept involves using a team leader and other team members in order to provide various approaches to nursing care for a group of patients. Team nursing concept is facilitated through the division of work where a medication to the patients can be given by one nurse, while other nurses will provide physical help to the patients (Kelly et al. 2016). In healthcare, team nursing concept will provide help to mix the skills including qualified nurses and experienced nurses. The quality of patient care in this nursing system is questionable as the care is fragmented into the team.

The primary nursing concept is associated with individualised, comprehensive and in this method; one nurse provides care throughout the period of care for an individual. As opined by Pauly et al. (2015), primary nursing practice emphasises mainly on continuity of care and one nurse completes the whole care for a patient. Therefore, the cultural awareness of the nurse needs to be well-developed as the nurse need to remain with the patient for all time. The nursing service in this method categorised in a way to meet the patient’s individualised care. Primary nurse communicates with the family members regarding service users’ health.

Identification of Literature Gap in the Study

In Progressive Patient Care (PPC) system of the method, service users are placed in the units based on their needs and medical speciality is given through degree of illness. According to Cherry and Jacob (2016), PPC is a systematic grouping of patients on the basis of the degree of illness rather than by classification. Elements of PPC are related to the intensive care units, self-care units and intermediate care units. In this nursing system, the nurses need to know about the culture of the patients and hospital facilities need to be strong.

The user-centred approach can increase the visibility, constraint and affordance of functions in a healthcare home. Visibility can be increased by following all the factors and norms in the healthcare. As stated by Wager et al. (2017), affordance is related to the activity of the nurses. In addition, nurses need to avoid the reliance on memory in workplace functions. Nurses can simplify the process and standardise the workplace process. Nurses need to decrease the process to use the memory in problem-solving process in the workplace (Banks and Kelly 2015). Establishing the norm to follow the code of ethics in nursing will eventually help to simplify the process of working. Moreover, nurses attend the work-safety training and they have ideas about work-loads, work-hours, distraction and interruption in safety. Interruption process can lead to medication administration error in order to indicate the safe zones in healthcare home.

Nurses need to prepare knowledge on patient safety and they should avoid reliance on vigilance. Doctors keep the vigilance on patients' safety with checklists, well-designed alarms, adequate breaks and rotating staffs. In the health care homes, management uses alarms in order to alert the nurses in potential emergency and nurses can get benefits in scheduling in the overall process. Nurses are given training for the team collaboration and this training is given on interpersonal communication (Holland 2017). This type of training increases effective communication among the nurse. It allows the service users to have better service from various ethnic group nurses. This training also provides knowledge about cultural safety and it essentially provides information about involving patients in their own care. Nurses have to take the decisions from the family members of the patients and nurses offer educational information of the diseases of the patients to their family.

According to Ramsden (2013), nurses need to understand about service users' culture and various cultural identities can lead to effective health care strategies. The management of healthcare needs to create a non-biased culturally safe place that can demean the healthcare safety of the service users. In a healthcare setting, poor cultural safety is related to the poor patient concordance, mistrust and miscommunication (Chartier 2014). Nurses spend more time with service users and there is a thin line between suboptimal outcome and patient experience. There is no difference between patient safety and clinical quality. The nurses provide care to the patients in a safe and effective way that do not differentiate through culture and religion. Key drivers of loyalty towards work is the team working, listen to the issues and cleanliness in hospitals. If the healthcare professionals work as a team, the service users feel safe (Papps and Ramsden 2016). On the other side, cultural safety healthcare organisations need sustained leadership that can facilitate the nurses' commitment towards the workplace.

Leaders in healthcare should demonstrate accessibility and visibility of patient safety. Leaders must be observant and leaders can ask open-minded questions to create transparency and openness. There is a need to create a purposeful connection between patient safety and relationship of patient-nurse (Ding 2014). In addition, some of the critics opined that safety in healthcare is related to the safety of both patients and healthcare professionals. Patients and nurses need to interact frequently and their behaviours can show a bond. A cultural shift in nursing is one such crucial thing identifies the importance of mutual respect between nurses and service users and they must be inclusive, holistic, culturally sensitive and non-judgemental in order to show their affection towards each other (Holland 2017). Nurses must have not any preconceived notion regarding service-users’ religion, faith and creed and orthodox thinking frame eventually leads the situation to worsen. Nurses with this kind of thinking capability have a number of cultural difficulties and it provides a graphic illustration to identify discriminatory behaviour.

Safety in healthcare is a process related attribute and safety are different from quality in healthcare. Safety is not perceived as a process of aggregated value. Safety in the healthcare is manifested as a non-event and the management tries to stop unwanted events. Safety improvement requires preventive management approach and proactive management approach to act before the fact occurs. As opined by Polaschek (2015), safety is a shared value within the healthcare organisation. In addition, culture is another unspoken language in order to respond to secret complex code within a healthcare. Values are surrounded by symbols, rituals and practices within healthcare homes. Symbols are associated with visible that are associated with the external observer. Rituals are related to the cultural meaning and they are being understood only by those who belong to the culture. Values in a healthcare are unconscious and not directly perceived from outside and it can only be deduced to the way people act in certain circumstances.

Organisational culture is associated with shared values and common beliefs; these interact with the structure of healthcare and control system in order to produce behavioural norms. Organisational culture is dynamical, continuously, socially constructed by the people who constitute a healthcare centre. According to Williams (2016), organisational culture is characteristic that is manifested by the individuals’ behaviours and attitudes. Holistic management approach in a healthcare home is related to human factors, technical factors and organisational factors. Human factors are associated with knowledge, skills, motivation, attitude and behaviour. In addition, technical factors are associated with ITC systems, equipment, components, quality assurance and maintenance. Organisational factors are associated with infrastructure, strategy, resources, processes and procedures. Safety culture enhancement can imply organisational change and safety culture is a mixed method to create an intangible complex social concept (Memish 2014). Safety culture is a tangible factor to remove the hazardous issue. External and internal drivers can impact on organisational performance improvement. Organisational performance is related to the management, economics, quality, safety, health, environment and social responsibility. The change in a health care can be brought from present state to the desired state through managing the change process and through strategic vision (Pauly et al. 2015). There are several other factors that are associated with leadership, decisions and attitudes, management system, type of intervention and organisational culture.

Nurses in health care homes face the challenge in terminology confusion and they do not have a basic concept how culture relates to a cultural safety issue. Terminology issue is vital in a healthcare home as nurses need to communicate with the service providers with accurate terms. In addition, nurses can face lack of support from the management and educators to improve the knowledge base, pedagogical approach and teaching skills. As stated by Arieli et al. (2014), the word ‘culture' is unclear to the learners of nurses and they thought that the culture is limited to the race and ethnicity. Culture safety concept is beyond the understanding and ethnic-specific knowledge is related to the position of power, cultural customs and nurses can apply the knowledge in the workplace also. Carayon et al. (2014) supported this idea by saying sometimes leaders in a healthcare do not support the nurses by cultural safety education.

Each of the leaders and educators has their own set of interpretation in culture safety framework. Lack of support and lack of education of nurses for cultural knowledge can lead to cultural inequalities. Leaders and educators feel unprepared when they teach about sensitive topics to the nurses like racism, marginalisation. Cultural safety has two distinct perspectives, paradigm shift and continuum. Continuum is about cultural safety as the outcome of being culturally competent. On the other side, a paradigm shift is about transferring the power in the nurse-patient relationship. Transferring the power can foster the self-determination and it supports the patient participation (Williams 2016). 

People can get satisfied with physiological contentment; however, there is more demand for satisfaction. In recent time, in the healthcare sector, dramatic changes have come into technological, economical, liberalisation, privatisation and globalisation policies and electronic data interchange facilities and they motivate the healthcare sector to improve the service quality (Graban 2016). Service quality needs increase for changing the lifestyle of the people. Lifestyle of the people is associated with an increase in affluence, leisure time and women in working places. In addition, changing world has brought the greater demand for lawn care, travel agencies, entertainment, daycare centre and home help (Weller et al. 2014). Changing economies in daily life has brought changes in factors like globalisation and deregulation. Changing technology in healthcare has brought the demand for service quality as new technologies increase the demand for service. Highly satisfied service users become loyal towards the healthcare centre. The satisfaction-loyalty relationship is divided into three major categories, affection, indifference and defection (Pronovost et al. 2015). Defection is related to low satisfaction, indifference is associated with intermediate satisfaction level and affection is related to highly satisfied level.

Dekker (2016) opined that consumers evaluate the quality of service as the result of gap between perceived quality and expected quality. Therefore service quality is perception minus expectation. Service Quality Model emphasises on determinants of service quality like access, communication, courtesy, credibility, reliability, tangibles, understanding of the customers and security. The authors devised an instrument named SERVQUAL and it is questionnaire to measure the service quality of the healthcare. Knowledge gap is about difference between nurses’ belief about customer expectation and actual needs of the service users. In addition, standards gap is the gap between quality standards and perception of customer expectation. Delivery gap is about difference between actual performance and specified delivery standard (Kansra and Jha 2016). Service gap is about difference between customer expectation and the perception of the customers. SERVQUAL is specified overall gap between what is delivered and what is expected. Service quality concept is relative and it is not absolute. Moreover, quality can be determined through customers; perception, not by the healthcare professionals. Service quality can be gained through exceeding expectations of the service users.

Healthcare management are concerned about losses and profit; however, they have to be concerned about management efficiency. Culture Care Theory provides a framework for giving services to the diverse population and it gives an approach to promote culturally congruent nursing to different people who have similarities and differences in well-being, health and illness (Zineldin et al. 2014). Healthcare management efficiency can be increased if the nurses get training about safety of the service users and cultural factors of the service users. Enterprise Resource Planning can be used in healthcare in order to increase the healthcare system. Implementation of ERP system can smooths the work process in healthcare stopping the impediments. ERP can heal the project if it costs more than budget and if it takes longer to implement the project.

The efficiency of process in healthcare incorporates about operational practices and planning that can reduce the negative impact on clinical services. Efficient people is needed to enhance the quality of service as the challenge to deliver better service lies in efficient nurses who can adopt innovative way to communicate, providing services and technologies (McFadden et al. 2015). In addition, collaboration is needed in workplace with better infrastructure that can improve the potential problems and it can engage stakeholders in healthcare process. Technologies in healthcare will eventually improve the success factors. The challenge lies to balance the complexity of implementation and cost. Application of technologies will eventually help the transform the information and it will also increase the service quality. Moreover, it is needed to implement the solution effectively with right outcome. Implementation of system needs to support the key consideration of the business with objectives, people-centric process and ROI (Winters et al. 2016).

The cultural safety concept and framework have many positive implications for nurses in Arab country and many nurses are there in Arab communities to provide health services. Nurses have to treat the patients have different views, religions and differently aware culturally. Making culturally safe healthcare may promote the retention of the nurses more and safety and quality of the service users can be ensured through this. Nurses face the issue to adjust institutional climate, emotionally and socially alienation when promote the cultural safety. Cultural safety helps to improve the patient safety culture and service quality of the hospitals eventually increases. Improvement of hospital performances is needed in order to ensure better performances of the nurses. Nurses will understand the cultural safety at workplace and it can promote the standard of services to the patients. Cultural safety is a guide to the nurses to work in multicultural environment, however, the encounter of the patient and nurse is bicultural encounter (Margaret et al. 2015). The cultural safety framework has its potentiality in order to create attention to legitimacy of differences to raise aware of patient safety.

In this section of the study, cultural safety and quality in healthcare has been specified with identification of issues. The discussion has been done using secondary sources and culture of nurses has not been overemphasised, service users’ quality care has also been discussed. In Arab, culture safety is important aspect as there most of the nurses are believers of Islamic faith. Simplified application of cultural safety can promote reductionist viewpoint to find the issues in ethnic groups. In Arab, cultural safety needs to make an impact to take grass root initiative in order to understand the complex pedagogy. Theoretical perspective has to be used in practical spheres and cultural safety framework can be included in government planning and public policy. 


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